An interview with Prof. Thomas Zeltner, Chairman of the WHO Foundation, on the influence of oral health on overall health and the growing need for dental professionals to practice truly healthy dentistry.
It is known that oral health has a direct impact on general health. Pathogenic bacteria in the oral cavity can infiltrate the inner body and lead to systemic disease. Today, we know that numerous chronic diseases have their origins in the mouth. Because of this, oral health is becoming increasingly important and there is increasing interest from the public, politicians and international organizations. WHO is constantly assessing the global burden of disease in different countries. In the 2017 Global Burden of Disease Study, it was found that oral disease affects 3.5 billion people worldwide and that untreated dental caries is the most common health condition, a conclusion that shocked numerous international organizations, including WHO. Headaches were found to be the second most common health condition, and they’re often related to the mouth and to problems with dentures to some extent too. Hence, we see that the burden of disease is huge when it comes to oral health—far greater than anyone previously thought. Additionally, WHO has included oral health in the index of chronic noncommunicable diseases because they share the same roots. Excessive sugar intake and tobacco or alcohol consumption, for instance, don’t lead just to heart problems but also to oral health impairments. WHO has also agreed that there needs to be a greater focus on oral health in relation to the healthy aging of populations, and that dentists need to rethink their material choices and to start practicing truly healthy dentistry.
What impact does oral health have on overall health?
Bacteria in the mouth can infect the tissue around natural teeth or dental implants and will then start migrating downward while destroying the tissue and eventually infiltrate the inner body, bypassing the impaired epithelial barrier. As such, the pathogenic bacteria gain access to the bloodstream and start spreading all over the body, facilitating systemic disease. For instance, we now know that heart disease like valve infections can initially be triggered by tooth infections. Another area of concern is the immune inflammation responses triggered by oral disease of infectious origin, like periodontitis, which, if unresolved, leads to a disruption of the systemic immune system and the development of a chronic condition.
What role do dental implants play in this context?
Today, one of the major risks of dental implants is that nanoparticles can dissolve and accumulate in the periimplant tissue, leading to inflammation of these tissue and overall health problems years later. WHO has realized that metal implants especially are connected with infections of the surrounding tissue because of those very nanoparticles that can dissolve. These infections then produce a myriad of side effects and resulting long-term health problems. Here, we clearly again see the mechanism of how a relatively small problem that started in the mouth can become a problem of much wider concern down the road. Moreover, many antibiotics are administered to treat these infections, increasing the risk of antibiotic-resistant bacteria.
What should dentists ask themselves before choosing a specific implant material?
In the past, implant dentistry used to be relatively simple and safe for patients. However, technologies have evolved and become increasingly complex and potentially dangerous for patients as a result. In this context, it is important that dentists choose the right material for treatment, a material that is nontoxic and therefore does not influence the overall health of patients negatively. Currently, the implant material primarily used in dentistry is titanium, followed by ceramics and polymers. Dentists should take a close look at these materials and ask whether they are toxic. Arguably, a material inserted into the human body should always be nontoxic. One should always consider the debate around mercury, amalgam and other toxic materials. Also, dentists should ask themselves whether implants of these materials will protect patients from infection. Of course, infections around implants should be minimized as much as possible. Dental implants are always subjected to attacks by bacteria in the oral cavity, an environment filled with potentially pathogenic bacteria, which poses a great risk of infection if the implant does not offer a sufficient bacterial seal of the soft tissue. Moreover, dentists should ask themselves whether some implants produce more microparticles than others, again increasing the risk of infection, and what the body’s reaction is to these different materials when it comes to immunology. Dentists naturally want to offer their patients an implant material that avoids these difficulties. We are currently in an interesting phase in dentistry because titanium, which has been used primarily in implant dentistry for the last 50 years, now has new competitors, like zirconia. It’s becoming increasingly clear that zirconia has some advantages over titanium as an implant material.
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Why should dentists reflect on their material choices sooner rather than later?
I’m currently involved in research on the huge global effort to look into outcomes of primarily surgical interventions. The goal is to establish a consensus on how to measure surgical outcomes, assess their success in terms of survival, quality of life and well-being, and communicate that to politicians. At the end of the day, we should be able to compare the success of surgical interventions in the U.S. with that in European countries, and that is only possible when you have comparative data. Oral health will definitely be an important part of this exercise. As a result, dentists will be in the limelight in the years to come and the long-term surgical outcomes that they produce will increasingly be scrutinized by the public and politicians. On the one hand, I suspect most dentists will be happy about getting much more political attention in the future. On the other hand, some dentists might be worried because politicians will be looking more carefully at what they are doing. For this reason, dentists should reflect on the materials they put in their patients’ mouths and start using materials that are as healthy for patients in the long run as possible. We, as healthcare professionals, are all responsible for thinking about the future, the long-term outcome, what happens in ten years from now, and not only tomorrow. We should constantly ask ourselves what influence our decisions have on the long-term health of our patients.
How exactly is oral health connected to healthy aging?
As mentioned before, oral health is connected to overall health and the materials that dental professionals put in their patients’ mouths therefore have a direct impact on whether they age in a healthy way or not. If patients start developing long-term complications from dental treatments 30 years later, for example, their quality of life is reduced significantly. Failing dentures and dental implants are among the major problems experienced by elderly patients worldwide. When they are not able to eat properly because of pain, they often start to isolate themselves, leading to depression. For this reason, in May 2021, the World Health Assembly passed a resolution for better oral health, inviting the international community and all its member states to establish strategies for promoting oral health on a national level and to include oral health in their plans to promote the healthy aging of their populations. WHO will closely monitor their progress and assess whether they have succeeded in establishing national oral health plans by 2030. Healthy aging is one of the priorities not only in high-income countries like the U.S. and European countries but also in countries like China and India, where we see populations becoming increasingly older. Of course, biocompatible implant materials, like zirconia, with which long-term complications (as occur with other materials) can be significantly reduced, play a major role in promoting healthy aging.
Dentists are often cautious about using a material that’s not been sufficiently documented. What would you consider to be sufficient in this context?
Generally, dentists are told to wait for clinical guidelines that are published in consensus statements by scientists, clinicians and experts and are based on clinical evidence and long-term data. Today, we consider the results from one- to three-year studies as short-term data, the results from five-year studies as midterm data and the results from ten-year studies as long-term data. However, it must be mentioned that long-term health complications often show up only after a much longer period. For instance, we’ve seen that some radioactive substances that were given to patients led them to develop cancer 30 years after treatment. I believe that results from five- to ten-year studies are considered to be really good scientific evidence. Moreover, the scientific developments around implant materials will only accelerate, considering that 80%–90% of scientists who have ever lived are alive today and that 80%–90% of research findings will be published during our lifetime. We are living in an incredibly dynamic scientific environment with a huge amount of research being done on a daily basis. I personally think that the data regarding zirconia implants is so convincing that I would urge dentists to really look into them and start using them—not in five years’ time but today. In this light, I would like to conclude by saying: the future is yours.